Antibiotic prescribing practice in the spinal cord injury system of care

Edward Hines Jr Va Hospital, Hines IL

Investigators

Abstract

Individuals with spinal cord injury or disorder (SCI/D) are at high risk for infections compared to the general patient population due to factors such as frequent hospitalization, previous antibiotic use, frequent and chronic use of invasive medical devices such as urinary catheters, and development of pressure ulcers. Many of these infections are caused by antimicrobial resistant organisms such as multidrug-resistant gram-negative bacteria or Methicillin-resistant Staphylococcus aureus. Because infections often require antimicrobial treatment, the opportunities for over-prescribing of antibiotics or inadequate antibiotic prescribing are common. The goal of antimicrobial stewardship programs are to optimize antibiotic use by limiting overuse and improving inadequate treatment while minimizing unintended consequences such as the selection of antibiotic resistant organisms. Antibiotic resistance increases the likelihood of initial inadequate therapy. Inadequate antibiotic therapy refers to treatment that does not have `in vitro' effectiveness against a particular microorganism; in other words, the microorganism is not susceptible to the particular antibiotic prescribed. There is a well-documented need to prevent inadequate antibiotic treatment of infections, due to its impact on patient outcomes, through the implementation of antimicrobial stewardship resources and programs. Antibiograms (summaries reporting resistance of all tested microbiology isolates from patients at a facility- or unit-level) have been shown to be an effective intervention in improving empiric prescribing. In persons with SCI/D, this is even more important due to their increased risk of infection. However, very little work has focused on identifying modifiable patient, provider, and/or system level characteristics associated with inadequate antibiotic therapy in treating these common infections among individuals with SCI/D; nor in implementation of effective antimicrobial stewardship interventions such as using antibiograms. VA services for Veterans with SCI/D are delivered through a hub and spoke system of care, extending from 25 regional SCI/D Centers offering primary care and specialty care by multidisciplinary teams (hubs) to the 134 SCI/D Primary Care teams (spokes) at local VA medical centers. Understanding the impact of this hub and spoke system in provider decision-making is needed to ensure effective antimicrobial stewardship strategies that reduce the prevalence of inadequate prescribing as well as decrease the negative impact of related outcomes, such as higher hospital admission and mortality rates. This is important to assess considering that up to 50% of SCI patients may only be seen in a VHA facility without a specialty SCI/D Center. The proposed study addresses the SCI QUERI strategic plan priority area of improving treatment and management of infections in Veterans with SCI/D and will focus on Steps 3-4 of the QUERI process. As part of an overall goal of improving antimicrobial stewardship in this population, we propose to conduct a national mixed-methods study to assess variation in inadequate prescribing in BSI by hub and spoke facilities and implement a pilot antibiogram intervention to improve prescribing.¿